Speaker Request Form

Please take a moment to fill out the following form. The in-depth information you provide will enable us to identify a fitting speaker, prepare the speaker for the event and ultimately ensure we meet the expectations of you and your organization.

Please allow at least one month to process your request, but no more than three. (* indicates a required field)

Contact Information

Primary Contact Name	*
Primary Contact Phone Number	*
Primary Contact Phone E-mail	*
Alternate Contact Name	*
Alternate Contact Phone Number	*
Alternate Contact Phone E-mail	*

Event Information

Event Name	*
Regional Location	*
When will this event begin?	*	req format YYYY-MM-DD
When will this event end?	*	req format YYYY-MM-DD
Physical Address of the event?	*	Please provide the exact location of the event (512 Char Limit)
Phone number of the event location	*
On what day and at what specific time do you need the speaker to start his or her speech?	*
Is this request on behalf of a host organization?	*	Yes No
Organization's name		If you are requesting a speaker on behalf of a host organization please provide the name of the organization
Is the sponsoring organization a civic organization?	*	Yes No
Does the event have the official backing of the local government?	*	Yes No
Does the sponsoring organization exclude any person from its membership?	*	Yes No This includes practicing any form of discrimination in its functions based on race, creed, color, sex or national origin.

Speaker & Attendance Information

What type of speaker are you requesting?	*
Attire	*
Expected Audience Size	*
Audience Make-up	*	Students Faculty Citizens Organization Members
Speech Topic	*
Audio/Visual Support	*	Yes No
Sequence of Events	*	Describe the sequence of events from the speaker's arrival and continuing through until the speaker's departure. (512 Char Limit)
Will the media be invited?	*	Yes No
How will the media be invited?		Leave blank if media is not invited. (512 Char limit)
Are there media/photography requirements for the speaker?		Leave blank if there are no requirements. (512 Char limit)
VIPs	*	(512 Char limit)
Is the speaker permitted to bring his or her spouse?	*	Yes No
Closest Military Lodging	*	(512 Char limit)
Closest Civilian Lodging	*	(512 Char limit)
Closest commercial airport	*	(512 Char limit)
Additional Information	*	Please provide any additional information you think we should know. (512 Char limit)

Security Question

4 + 3	*	Please enter the answer to the preceding math equation. (If the equation were "1 + 1 = ?" you would enter "2".)

Terms & Conditions: By submitting this form on behalf of yourself or your sponsoring organization you certify that the information provided above is complete and accurate to the best of your knowledge. You understand that representatives from USCENTCOM will contact you to discuss arrangements and costs involved prior to final commitments, or to inform you of an inability to support this event. You also understand that operational commitments must take priority and can preclude a scheduled appearance at an approved public activity.

Privacy Act Statement:
Authority: 5 USC 301; 5 USC 552 Principal
Purpose: To obtain necessary information so that a response can be provided to your Speaker request.
The confidentiality of communications sent via the Internet can not be guaranteed and the electronic submission of your Speaker request is purely voluntary.